Archive for the ‘diagnosis’ Category

Patients invariably want to know what diagnosis I’ve given them or the papers from somewhere else say they’ve been given. Some don’t ask. Many do. To those who do I’m really, really tempted to say, “What’s it to ya?” but I’d just be dismissed as being flip or, even worse, that I’m with holding some secret that will help do something, though I’m not sure what. Most of the time patients don’t know what that information is going to help either. I do tell patients that I’ll tell them but first I’d like to know what having that information is going to do for them. Most of the time the answer is something vague, like, “I just want to know what you’re writing about me,” or “I want to know what I’ve got.”

I know, you’re looking for an answer. You want to be told you’ve got Bi-Polar Disorder or Schizophrenia, or something, anything, as long as it has a name. Giving your condition a name explains what you have and then explains a course of treatment, right? That’s how it works when you go to the doctor. He says you’ve got Bronchitis, you take this prescription for antibiotic to the pharmacy, take a pill x number of times a day for y number of days and “you should feel better. If not, call me. Be sure to take all the pills.” OK, the doctor doesn’t say most of that, it’s written on the bottle the pills come in but it’s doctor (some doctor) who tells the druggist to put those labels on the bottle.

OK – you don’t really want to know you’ve been diagnosed with Schizophrenia or Bi-Polar Disorder because those are serious problems. So how about some depression or anxiety? Better? OK. Still, what does that tell you? There are clinical interpretations of those two words but I don’t really think that’s what you’re looking for because: there’s no antibiotic that you take for y number of days and it goes away. Medication can bring some relief, or so the pharmaceutical companies claim (more on that another time – I’m not anti-medication, just anti-miracle drug,) psychotherapy/psychoanalysis can bring some relief, the combination of psychotherapy/psychoanalysis and medication can bring more relief but, if you want real relief from what’s troublin’ ya (“What’s the matter bunkie? You say your brother hid your homework in the washing machine and now you algebra stuff is all over your underwear and the teacher is asking you to hand it in….”) you’ve got to change the things that are causing the condition, because that’s what your condition is a reaction to and a defense against.

We diagnose across five Axes (that’s acksees, not the things that have strings and make music), I-Clinical Disorders; Other Disorders That May Be a Focus of Clinical Attention II. Personality Disorders; Mental Retardation III – General Medical Conditions IV – Psychosocial and Environmental Problems and V – Global Assessment of Functioning.

When you ask me what is your diagnosis you’re usually asking me for the top item on the list. I hesitate to tell you because it doesn’t tell you anything about what’s going on. It barely tells me what’s going on. What it tells me is that your symptoms, your reactions to your General Medical Condition added to your Psychosocial and Environmental Problems, have been given this or that name and number by the taxonomists who need to track these things for statistical and other informational purposes, like whether you can have coverage under the new parity law or not (another post another time.) Same thing about Axis II except that’s more pervasive, more of a character style, than just a bunch of symptoms.

What you’d be asking if you knew what to ask is what do I see as the things that are pushing and pulling on you that are causing you to be this way. You’d be asking me ” How do I increase my GAF (Global Assessment of Functioning) so I can _____ (insert desired result here.)

Doesn’t matter. I’m still going to hear “What’s my diagnosis” or its variant “I took a test (looked it up, whatever) online. I’ve got this. Do you agree?”

Drugs.com recently posted an article about ADHD that – wait – you don’t get news from drugs.com? How else are you going to find out about new drug approvals by the FDA, breaking information about recalls & lots of other useful stuff? Where else are you going to get articles like the one about which I’m commenting?

OK. So they posted this article about studies involving hand movements and ADHD which had some interesting points. One study found that children with ADHD weren’t able to perform the finger-tapping exercise without extraneous movements that weren’t as apparent in “typical children.” Another demonstrated that magnetic pulses caused movements in ADHD children to a greater degree than “typical children.” They said something about myelination of the left/right brain connective nerve tissue, the brain’s “braking mechanism” on movements, and a demonstration of why ADDers have a problem with keyboards and fine hand movement tasks. The article also said that there wasn’t a clear “clinical” application for the outcomes of this study or these tests.

Whoa! That’s a lot of stuff there, compadre! First of all, does anyone other than me have a problem with comparing ADDers to “typical” children? Typical? What are they saying? Who are they stigmatizing? How about calling those “typical children” as having “Attention Surplus Disorder” (thank you Thom Hartman.) Typical indeed. Read Harte’s anthropological & historical view of ADD in “Think Fast: The ADD Experience,” T. Hartman & J. Bowman, 1996, Underwood Books,(link to Amazon page for the book,) a book of excerpts from the Compuserve (remember that) ADD forums. Typical! Poppycock!

Next: What do you think of a parent that allows his/her child to be subjected to “magnetic pulses” as a form of testing without knowing the outcome? Even with knowing the short-term outcome. I realize that it’s hard to test pediatric effects and dosages but, really…. “God said, ‘Abraham, kill me a son.'” (“Highway 61,” B. Dylan, as if you didn’t know) but Abraham was spared from having to do that by the substitution of a ram at the last minute (insert computer and RAM joke here.) How do you feel about parents submitting children to experiments in the name of science? Me, I believe in things between consenting adults being permissible (within limits) but how does a parent consent for his/her child to be subjected to “trans-cranial magnetic pulses” – zapping the kids brain with magnetic charges – to observe if his/her arm jerks in response.

Finally, and this is the big one for me, and the whole point of this post: No clinical application? Are you ferreal? How about the simple “clinical” value of a piece of psychoeducation? Being able to tell a frustrated parent that the fidgeting child doesn’t have anything wrong with him, that it’s just the way his brain works and let’s find things that will help him learn instead of beating him down for not being able to sit still. How about being able to tell the child who doesn’t have the same fine motor skill as some of his buddies that, believe it or not, that will develop with time but, in the mean while, what can you do that they can’t because that’s what makes you special. How about using the information to educate teachers so they can learn that the kid who gets up from his seat to watch the squirrels running in the ivy on the side of the school building is also learning something, probably already finished the assignment, and is preventing himself from being bored (and getting in trouble for fidgeting.)

How about forgetting this ADHD vs “Typical.” Treat a child like he’s defective and you get a problem child. Treat a child like he’s a member of the family and you get a member of the family who can use his gifts. ADDers aren’t defective. Just different. If you think they frustrate you, you have no idea how frustrated the ADDer is – but that’s for another post.

This one’s gonna be touchy. I’m not all that clear about putting this post up there. It could be nothin’ but net, could be a brick. I’m sure this is going to make some people unhappy on both sides of the couch but, I gotta say something & so, as Wellington said to his mistress when she threatened to make his letters to her public, “Publish and be damned,” though I probably already am. It’s a professional liability.

This is written in part for patients, in part for therapists, and in part to get it off my chest ’cause its been there for a while & it’s startin’ to feel like a 10-ton safe. Here goes and if it bends you out of shape, so be it.

I was in the elevator going up to my office a few weeks, maybe a month and-a-half ago with 3 other people. Two were therapists, one was, I think, a patient. One therapist asked the other about his next patient & the comment came back something along the line of “He’s a real borderline.” The other said something like “yikes,” and then followed with a comment about being told by some mentor that you shouldn’t have more than one on your caseload. The one who made the comment in the first place said something about that being right. If you’re reading this and you recognize yourselves, I’m not picking on you. I’ve picked you as an example. If you’re offended you can take it up with me. Leave me a comment. Please. If you have an opinion about what I’m saying here, please, leave me a comment.

The whole time this exchange was proceding I was uncomfortable because I wanted to say something to this pair. The other guy in the elevator (remember him, the patient looking guy?) was looking decidedly uncomfortable and unhappy. I wanted to tell this pair to pipe down, that there’s other people on the elevator. Mind you, they didn’t say anything that might identify the patient (other than that he’s a he.) The behavior broke no privacy or confidentiality rules, HIPAA was certainly not violated. So, what’s my beef?

That’s easy. It makes patients uneasy when they hear this. They already think we talk about them when they’re not present. They have wonderful imaginations and are very sure we talk about them. There’s no need to prove them right. It doesn’t make them happy and gives them a not great opinion of us because, they think, it tells them what we think of them.

We’re not even going to talk about the categorizing of a patient with an unflattering label. We all know what borderline means, and that includes patients. It means difficult, explosive, unmanageable, right? Too bad it didn’t mean that when it was first proposed, but that’s what it’s come to mean. But I digress….

My point here is this: I was fortunate. My first internship was, in part, at the James A. Peters Veterans Medical Center in the Bronx where there were signs on the two side walls of each elevator reminding the staff to not discuss patients in the elevators because staff, patients and patients’ families all share the same elevators. Good signs to post because people forget.

What I’m saying to therapists – pipe down! If you must talk about patients, and I’ll be generous and say that you’re “consulting” with a colleague, do it in your office or your colleagues office and do it with the door closed. Not in the hall. Not in the elevator. Not in the toilet. Let’s show them the respect they deserve.They come to us in pain and we’re not here to add to it by hearing us talk about patients (in the pejorative) in public. We’re not carnies and our patients aren’t Rubes. If you can’t pipe down, and you’re in a public place with me, expect that I’ll ask you to hold it for when you’re alone. I invite any other clinician to do the same when they hear another of us doing this.

By the same token I’m saying to patients that it’s OK to tell the therapists who are having this conversation in front of you that they should zip it. Tell them not to have this discussion in front of the kids. Tell them that you feel disrespected. Tell them that they’re treating you like you’re not there. They may get huffy. Let ’em.

OK, now for the kicker. The something more. This information that lives with your insurer and their insurers isn’t finished yet. What happens if you apply for life insurance? An auto loan? Change jobs and need to sign up for other health insurance? Apply for a credit card? Have you guessed yet?

That’s right. These worthies will often turn to an agency that they hire to collect your information, your protected health information, and that agency will then turn to me and request the records of your treatment. They will sometimes accept a summary but I have to tell them that’s what they’re going to get. What you’ve signed, after you first told them that you had this treatment (if they ask, and for life insurance they sure will,) is a consent for release of information for your medical records. That means they are going to be requesting my session notes (which are part of your official medical record.) This also means that this 4th party outside of the triangle of you, me & your insurance company (and their backers, but I included them in the triangle – so what if it’s got 4 sides? I’m a psychotherapist not a geometer) has your protected health information in its data bank. Yes, the release you signed is HIPAA compliant. They know the law & know that that’s what they have to give you. It doesn’t mean that they are as careful about disclosures as your psychotherapist (me, in this case.)

Does this chill you a bit? If it doesn’t then you’re not following the flow of your information. Wider and wider circles of dissemination.

Now, I’m not saying that if you and I keep things between us and you leave your insurance out of our relationship that you won’t at some point decide that you want life insurance and they won’t ask about treatments you’ve received. If you do they will. I won’t tell you not to tell them about treatments. That would be telling you to commit fraud and I won’t do that. I won’t tell you to lie on the application. I will tell you that, unless you are asked about treatments, in most cases (within the limits of the laws about confidentiality) it stays between you and me (maybe your accountant and Uncle Sugar if you claim it on your taxes, but I’m not going to go there.) There are limits imposed on confidentiality by law, such as if I think you are an immediate danger of committing harm to yourself or somebody else, or in case of suspected cases of child abuse but within the law what’s between you and me stays between you and me. Personally, I like it that way.

Another time I’ll tell you why I don’t like “diagnosis” as used in the DSM (or ICD,) but that’s not part of this. Let’s call it a day and I’ll go back to enjoying my cup of tea.

OK, where was I before I started brewing my tea – a nice Oolong with lots of flavor, good aroma & gentle bite? Oh, yeah, about codes and privacy. This section gets a little technical but hang in there, fans – it’s worth it.

I said that those codes don’t leave much of an artifact (footprint, trace, record) that’s going to make any difference, right? Wrong! There’s a procedural code for every procedure that goes on a claim form, whether it’s medical, dental, surgical, psychotherapeutic, etc. The procedure performed becomes part of your permanent medical record in your insurer’s database. “So what” I hear you say. So this: it’s not just in your insurer’s database. It’s in their insurer’s database. They’ve gotta lay their bets off somewhere. That’s with a meta-insurer (think AIG or similar.) Someone who does risk-management and determines how much they can back the bets your insurers make. Think of it as the insurance company has sold your marker to someone. You said it was Jake for them to do that when you signed the line that said that your information could be disclosed for the purpose of obtaining payment. And you thought it was just between you, me, and your insurance company. Have another thunk because there’s more.

Anytime there’s a procedure code there’s a diagnosis. Again, this is whether the work is medical, dental, surgical, psychotherapeutic, or whatever. Now we’re beginning to where it gets sticky. Diagnosis is a serious word. It means that, based on criteria established by the Taskforce that created the Diagnostic and Statistical Manual of Mental Disorders-IV TR, you get labled with a disorder. You are no longer “the worried well,” or someone who just feels anxious. You now have a recorded disorder. This is part of that marker. The fun doesn’t stop there….

Anything that is contained in the DSM-IV is contained in a book called the ICD-9 (going on ICD-10) – “The International Classification of Diseases” published by varoius publishers all putting out the same book (it’s used world wide – International, right?) This means that where ever your record is read they all read the same diagnosis. Great, right? Maybe if the people reading that record were also psychotherapists, psychiatrists, or some kind of mental health professionals, but they may not be. Yes, some insurance companies do utilize us for review but not all the reviewers are. This means that your case is being reviewed by a clerk of some sort. This clerk gets to decide (among other things) how many sessions we can have during a given year for a particular disorder, if any at all. They can also decide that treatment has gone on long enough based on the tables they have and what instructions they’ve been given. At this point it involves more work; usually for me and for which I don’t get paid but, again, even though I mention the do-re-me it’s not about the bucks. It’s about the time it takes to appeal the decision & meanwhile the treatment and who’s going to pay for it is in Limbo (which is often somehow contiguous with Hartford, CT or someplace in Texas, maybe offshore. Who knows?)

These clerks aren’t under the same constraints about the privacy of your information (remember, that’s what this is about) as I am. They are allowed to bundle it for research as well as developing their actuarial tables and other statistical purposes. Your personal information (PHI – Protected Health Information) is not as protected anymore.

But wait, as they say on the infomercials, there’s more. See part III, coming up shortly….

“Do you take insurance?” Yeah. I’m in-network (“par,” in insurance terms – participating) with several plans and take assignment. I’m not in-network (“non-par” – I don’t par…never mind. You get the idea) with many more than I’m in with. There’s various reasons for that, none of which really matter here. Feel free to email me if you really need to know but, trust me, that’ not what this is about.

Personally, I’d rather you not use your insurance. That way we can keep things just between us (the two of us, not the two of us and a lot of other people.) I know that you want to have your insurance company pay me (“par”) for part of your treatment or reimburse you (“non-par”) for some of what you paid me. It makes absolute cents. Dollars and cents. Unless you work for the exceedingly rare, and growing rarer all the time, companies that pay your entire premium, you pay a lot for your share of the premium on your health insurance. You want to get something for that hard earned cash that’s not going into your paycheck. Even if your policy doesn’t cover “behavioral health,” you may have a flex or cafeteria plan that you can use to cover some of the period of treatment, some sessions, something.

I get it. I feel the same way about my health insurance. I want to get something back for the money that’s paid in. It’s why we have insurance, right, so that we don’t have to pay the whole ginormous cost of examinations, treatments, medications, devices, etc., etc? Yeah, that’s all real swell but there’s a good reason, maybe several, why you should consider not using your insurance for your psychotherapy/psychoanalysis/mental health treatment. Can you guess what it is?

Money? No. That’s not it. Yeah, sure, I can ask for more money from you if you pay out-of pocket than the fees that the insurance companies “negotiated” in the contract for “par” situations. Even if I can charge you more if I’m non-par because I don’t have to accept the rate the insurance company wants to pay, it’s still not about the money.Please believe me on this.

OK, I’ll give you a hint: look at the title again. The part that says “…Privacy of Our Work Together.” That’s my big concern and needs consideration on your part before you simply say “I pay for the insurance and I want to use it where ever I can.”

Have you stopped to think about how I get paid or you get reimbursed? Of course you have. I do something that goes to the insurance company and they send me a check (or deposit to my account) or I give you something, you combine that with something else, send it to the insurance company and they send you money. Simple. As easy as 3.1416.

Not so fast, Kimosabee. What’s on that claim form that goes to them? The CPT code (that tells them what procedure was performed, e.g., 90806= O(ut)P(atient) psychotherapy, 45-50″ (minutes,) no med(ication) eval(uation.) That tells them how much they pay out for what went on in the room. We can all agree that this is pretty harmless and doesn’t really do much in the way of leaving an artifact, right? Wrongo! Let’s move on to part II of this and I’ll explain more. For now my tea is ready to brew. See you in a bit!